Treatment of motility disorders with a gnrh analog

ABSTRACT

A treatment to alleviate the debilitating symptoms of motility disorders including the functional bowel diseases. Treatment of patients with analogs of GnRH significantly reduces or elmininates the symptoms of motility disorders, including bowel disease.

FIELD OF THE INVENTION

The present invention relates to the treatment of functional motilitydisorders including diseases of the autonomic nervous system ofidiopathic or known causes. Treatment of Functional Bowel Disease ordisease of the irritable bowel, as well as the autonomic dysfunction ofdiseases such as scleroderma with an analog of GnRH is disclosed.

BACKGROUND OF THE INVENTION

Motility Disorders include those diseases characterized by anabnormality of the autonomic nervous system. These include diseases ofidiopathic or known causes such as Functional Bowel Diseases andautonomic neuropathies of diabetes, scleroderma, and Parkinson'sDisease.

Treatment of the diseases of the autonomic nervous system has beenlimited to a few drugs approved by the Federal Drug Administration. Themost common drug therapy has been with metoclopromide, a dopamineantagonist or with acetylcholine agonists such as bethanecol. Suchtherapy has had limited success in patients with mild to moderatedisease symptoms. New experimental drugs tested for the treatment ofpatients with disease of the Autonomic Nervous System include the drugsdomperidone (dopamine antagonist which does not cross the blood-brainbarrier) and cisapride which enhances release of acetylcholine. Whilethese experimental drugs provide limited relief of mild to moderatesymptoms, they have not been effective for patients with severesymptoms.

Chronic, unexplained abdominal pain, nausea, vomiting and altered bowelhabits are common symptoms of the intractable bowel disorders presentlycalled "Functional Bowel Disease" or "Irritable" Bowel Syndrome. Thecause and pathophysiology remain unknown, but evidence suggests that thedisease may be related to abnormalities of intestinal smooth muscle orthe enteric nervous system, or both, and is a systemic problem (Mathiasand Finelli, Contemporary Issues in Gastroenterology, S. Cohen and R. D.Soloway (eds) Vol. 639-59, 1987).

A recent survey by Mitchell and Drossman (Gastroenterology 92:1283-1284,1987) found that 47% of patients seen by gastroenterologists hadfunctional complaints; i.e., gastrointestinal symptoms in the absence ofobjective findings. A similar survey of certified specialists ininternal medicine indicated that 13% of their patients had chronic painwithout objective findings (Margolis et al., Pain 20:151-156, 1984).

In these functional diseases, women are more commonly affected than men,with the ratio approximately 20:1 (women:men) (Mathias and Finelli,1987). Often these patients are considered psychoneurotic (Woodhouse andBockner, Br. J. Surgery 66:348-349, 1979; Drossman Am. J. Psychiatry139: 1549-1557, 1982) and told they must live with their problems.Psychotherapy, in general, has not added much to improve the generalcondition of those with moderate-to-severe functional disease.

Recognized syndromes of Functional Bowel Disease include GastroduodenalMotor Dysfunction, Intestinal Pseudo-obstruction both idiopathic and ofknown cause, Idiopathic Intestinal Hollow Visceral Myopathy/Neuropathy,Severe Intestinal Constipation and Post-Vagotomy Syndromes such as theRoux-en-Y Syndrome. Previously, these diseases were thought to bedisorders without an organic basis, however, recent evidence nowsuggests these diseases involve alterations of both the muscle of theintestinal wall and the nerves of the myenteric plexus (Mathias andFinelli, Contemporary Issues in Gastroenterology, Vol. 6, Cohen andSoloway, eds., New York, Churchill Livingstone, 1987, pages 39-58).Recent evidence has also shown abnormal gastrointestinal motility inmany patients (You et. al., Annals Internal Medicine 95:449-451, 1981;Rees et. al., Gastroenterology 78:360-365, 1980; and Mathias andFinelli, 1987). Treatment of such patients has been by medications suchas opiates, to enhance gastrointestinal motor activity, or antiemeticeffect (McCallum, American Journal Gastroenterology 88:1008-1016, 1985).Because of their effects on the upper GI tract, dopamine antagonistssuch as metoclopramide and domperidone have been tested for therapeuticeffects. Results of such therapy have varied, depending upon theantagonist, dosage, treatment regimen, and patient population, but ingeneral such therapy appears to lessen the symptoms of disease.

It would be of great utility to provide a novel treatment of FunctionalBowel Disease or Motility Disorders which would alleviate thedebilitating symptoms which characterize the disease.

SUMMARY OF THE INVENTION

The present invention provides a method for treating patients inflictedwith Motility Disorders comprising administration of a therapeuticallyeffective dosage of an analog of Gonadotropin Releasing Hormone (GnRH).GnRH analogs are peptides which exhibit GnRH-like activities in standardbioassays (e.g., modulation of gonadotropin release in cultures ofpituitary cells) and may be agonists or antagonists of GnRH. Thepreferred analog of GnRH is a decapeptide similar to the nativecompound, however substituted with one or more D-amino acids to preventdegradation of the peptide in vivo. Most preferred is an analog of GnRHof the formula: pGlu - His - Trp - Ser - Tyr - X - Leu - Arg - Pro -NHC₂ H₅, wherein X represents an amino acid in the D-configuration. Anespecially preferred analog is Lupron wherein X is D-Leu (TAPPharmaceuticals, Abbott Labs, North Chicago, Ill.).

Motility Disorders are characterized as those diseases havingdysfunction of the Autonomic Nervous System, both idiopathic and ofknown cause. These include Functional Bowel Diseases and AutonomicNeuropathies of diabetes mellitus, scleroderma, and Parkinson's Disease.The method of this invention is particularly effective in the treatmentof patients suffering from Functional Bowel Diseases, includingGastroduodenal Motor Dysfunction, Intestinal Pseudo-obstruction,Idiopathic Intestinal Hollow Visceral Myopathy/Neuropathy, SevereIntestinal Constipation and Post-Vagotomy Syndromes such as Roux-en-YSyndrome.

DETAILED DESCRIPTION OF THE PREFERRED EMBODIMENTS

The cause and pathophysiology of Motility Disorders, includingFunctional Bowel Disease remain unknown, however evidence suggests thatthese diseases derive from abnormalities of the autonomic nervoussystem, for example, the enteric nervous system.

Functional Bowel Disease is more commonly found in women than men at aratio of approximately 20:1, and the symptoms of abdominal pain, nausea,intermittent vomiting, and changes in stool habits may be exacerbatedduring the postovulatory phase of the menstrual cycle. During this phaseof the menstrual cycle, Luteinizing Hormone (LH), progesterone, andrelaxins are secreted. Progesterone is known to alter the function ofthe gastrointestinal tract in women during the menstrual cycle (Wald et.al., Gastroenterology 8: 1497-1500, 1981). Relaxins are known todecrease the contractile activity of smooth muscle of the uterus andcause a softening of the symphysis pubis (Weiss, Annual Review ofPhysiology 46:43-52, 1984). The effects of LH and the direct effects ofGnRH on smooth muscle or nerve are unknown.

One or more of the above factors, alone or in combination, may act as aprovocative substance in altering gastrointestinal function by affectingmuscles, nerves, or both. Administration of an analog of GnRH such asthe agonist/antagonist leuprolide acetate may inhibit the production ofthese reproductive hormones and thus provide effective therapeuticrelief for idiopathic abdominal pain, nausea, and intermittent vomitingin patients who are debilitated by functional bowel diseases. Inaddition, GnRH analogs may also exert direct effects upon the autonomicnervous system to provide therapeutic relief of such systems.

Naturally occurring GnRH has the following amino acid sequence:

    pE - H - W - S - Y - G - L - R - P - G - NH.sub.2,

and is degraded by peptides which cleave the molecule at the Gly⁶ -Leu⁷bond and at position 9. Numerous superactive agonistic analogs of GnRHhave been synthesized with a D-amino acid substitution at position 6 andoften with an ethylamide group in place of the C-terminal glycinamideresidue. The increased biologic activity of such peptides has beenattributed to their reduced susceptibility to enzymatic degradation, andtheir high binding affinity to GnRH receptors.

Both GnRH and its agonists possess the potential for inhibition of thepituitary-gonadal axis. Normal GnRH release from the hypothalmus ispulsitile. If the pulsitile pattern of stimulation is substituted bycontinuous administration of GnRH or its analogs, thegonadotropin-releasing mechanism is inhibited.

Many analogs of GnRH have been synthesized, and their uses in thetreatment of reproductive disorders have been disclosed. Known analogsof GnRH are listed in Table 1.

                  TABLE 1                                                         ______________________________________                                        KNOWN GnRH ANALOGS                                                            ______________________________________                                        pE--H--W--S--Al--G--A2--R--P--NHR                                             (A1 is Y or F; A2 is L, I, V, M, F, nL, or nV)                                pE--W--S--Y--G--L--R--P--G--NH.sub.2                                          pE--H--F--S--F--G--L--R--P--G--NH.sub.2                                       pE--A--W--S--Y--G--L--R--P--G--NH.sub.2                                       pE--H--W--S--Y--X--L--R--P--NH.sub.2 C.sub.2 H.sub.5                          (X is a D-amino acid configuration)                                           pE--H--W--S--R1--R2 R3--R--P--NH.sub.2 R4                                     (R1 is Y or F, R2 is a D-amino acid or synthetic                              amino acid; R3 is L, I, or nL)                                                pE--R1--W--S--Y--R2 L--R--P--G--NH.sub.2                                      (R1 is H, G, D, C, or D-amino acid; R2 is D-A)                                pE--H--W--S--Y--X--L--R--P--G--NH.sub.2                                       (X is G, a D-amino acid, or synthetic amino acid)                             ______________________________________                                    

Among the known analogs of GnRH the preferred compounds for use in thisinvention are forms of leuprolide acetate: D-leu⁶, Desgly-NH₂ ¹⁰,prothylamide⁹ and D-trp⁶, Desgly-NH₂ ¹⁰, Prothylamide⁹.

Additional analogs of GnRH are contemplated as useful in the method ofthis invention. These include analogs of substituted natural andsynthetic amino acids in either the D or L configuration; peptides ofgreater than or less than 10 amino acids, peptides with varied sugarlinkages and additional modifications which do not destroy the agonisticor antagonistic properties of the GnRH analog as measured by bioassay.

GnRH and its analogs are routinely used in the treatment of disorders ofthe reproductive system. Treatment to stimulate pituitary hormonerelease in patients with anorexia nervosa, hypogonadotropin anovulation,delayed puberty, cryptochidism, hypogonadism, and leiomyomata uteriusing GnRH analogs has been reported. Treatment to inhibit pituitaryhormone release in patients with precocious puberty, endometriosis,hormone-dependant tumors including prostatic mammary carcinomas,polycystic ovarian disease, and treatment for contraceptive purposeshave also been reported. To date, known therapeutic uses of analogs ofGnRH have been limited to treatment to correct reproductive disorders asdisclosed in the patents listed in Table. 2.

                  TABLE 2                                                         ______________________________________                                                             Disorder Treated by                                      Patent No.                                                                            Inventor     GnRH Analogs                                             ______________________________________                                        3,853,837                                                                             Fujino et al.                                                                              induction of ovulation                                   3,880,825                                                                             Sakakibara et al.                                                                          controlled release LH                                    3,914,412                                                                             Gendrich et al.                                                                            induction of ovulation                                   3,917,825                                                                             Matsuzawa et al.                                                                           hormone-dependent tumors                                 4,002,738                                                                             Johnson et al.                                                                             hormone-dependent tumors                                 4,005,063                                                                             Gendrich, et al.                                                                           induction of ovulation                                   4,005,194                                                                             Johnson      reducing prostatic hyperplasia                           4,008,209                                                                             Fujino et al.                                                                              induction of ovulation                                   4,101,261                                                                             Johnson et al.                                                                             female contraception                                     4,018,914                                                                             Johnson      induction of parturition                                 4,072,668                                                                             Amoss et al. pituitary release of LH, FSH                             4,229,438                                                                             Fujino et al.                                                                              immunoregulation                                         4,472,382                                                                             Labrie, et al.                                                                             prostate carcinoma                                       4,690,916                                                                             Nestor et al.                                                                              endometriosis                                            ______________________________________                                    

The present invention utilizes GnRH analogs in the treatment of anon-reproductive system disorder, namely, the treatment of motilitydisorders, as exemplified by the Functional Bowel Diseases and Autonomicneuropathies associated with such diseases as Scleroderma, DiabetesMellitus, and Parkinson's disease.

Without being limited by theory, the therapeutic effect of the GnRHanalogs in the treatment of motility disorders is thought to involve theinhibition of the pituitary-gonadal axis. Inhibition of the release ofthe pituitary gonadotropins Follicle Stimulating Hormone (FSH) andLuteinizing Hormone (LH) is thought to be at least partially responsiblefor cessation of the debilitating symptoms of the motility disorders. Inaddition, the inhibition of ovarian secretions including steroids andpeptides such as progesterone, relaxins, and inhibins may play asignificant role.

Treatment with GnRH analogs is generally by injection, which may beintravenous, subcutaneous, intramuscular, and the like. Treatment mayalso comprise drug implants with timed release nasal spray, injection ofa long-lasting depo form, or use of other modern advances in drugdelivery systems. It is contemplated that oral drug delivery may bepossible, but the analog must be one able to maintain the integrity ofthe peptide through the digestive system. The preferred route of drugdelivery is subcutaneous injection. The preferred dosage would vary withthe specific activity of the drug to be used, with the severity of thesymptoms of the specific patient, but would be sufficient to alleviatethe symptoms of the disease.

An additional variable would be the presence/absence of functionalreproductive organs, e.g. ovaries. It is expected that the effectivesubcutaneous dose would be in the range of 0.1 to 5 mg daily, with apreferred range of 0.5 to 1 mg daily. It is also contemplated thatadditional modes of administration of the drug may be used, and thatlower or higher doses may then be used, or that treatment may differfrom the daily administration illustrated. For example, a lower dose maybe administered by a continuous flow-pump, or a higher dose administeredin a depo form approximately once per month. The required dose is onewhich will reduce the particular symptoms of each individual patient.

The following examples are intended to exemplify one mode of use of thepresent invention, and are not intended to be limiting in scope orspecifics.

EXAMPLES EXAMPLE 1 Treatment of Five Patients with Leuprolide Acetate

Patients: Four of the five patients tested were women with functionalbowel disease: two with gastrointestinal motor dysfunction (GMD), andtwo with idiopathic intestinal hollow visceral myopathy/neuropathy(IIHVN). The fifth patient had Roux-en-Y Syndrome. All patients hadsevere, incapacitating symptoms of abdominal pain, nausea, andintermittent vomiting. All had made frequent visits to emergency rooms,had seen many physicians, and undergone multiple tests and surgicalprocedures, and were unable to maintain their jobs or quality of life.They had been treated with many different drugs, including experimentaldrugs by protocol. They had difficulty in maintaining body weight,because their symptoms were worsened by eating.

The symptoms of the two patients with GMD were abdominal pain located inthe right upper quadrant and epigastrium, daily nausea, and intermittentvomiting exacerbated by eating and by the luteal phase of the menstrualcycle. The two patients with IIHVN had abdominal pain, nausea, andintermittent vomiting, and also had urinary tract involvement consistingof pain and a decrease in urination. The fifth patient had Roux-en-Ysyndrome (defined as epigastric-to-right-upper-quadrant pain, nausea,and vomiting increased by eating) after surgical construction of agastro-jejunal Roux-en-Y anastomosis. The mean duration of thesesymptoms was eight years (Table 1). All subjects had undergone extensiveblood testing, several upper gastrointestinal x-ray series, bariumenemas, esophagogastroduodenoscopy, endoscopic retrogradecholangiopancreatography, gastric emptying tests with radiolabeled meal,ultrasound of the abdomen, computerized axial tomography of the abdomen,and many other tests. The results of all tests were normal, except forprolonged gastric emptying in the patient with the Roux-en-Y Syndrome.Because of their intractable clinical problem, these patients wereincluded in the test protocol with leuprolide acetate.

Protocol: The symptoms of each patient were first assessed, and theirtests evaluated. Each patient kept a daily symptom diary. Leuprolideacetate was obtained by prescription as Lupron (TAP pharmaceuticals,Abbott Labs, North Chicago, Ill.). One multi-use vial of Luproncomprised of 140 mg/2.8 ml Leuprolide Acetate. A daily dose of 0.5 mg(100 μl) was self-administered by subcutaneous injection, for a periodof three months. Each patient was examined at 0, 1 and 3 months oftreatment. After the third month, leuprolide was continued aspreviously, and estrogen (0.625 mg orally) and calcium (1000 mg orally)were also administered. At the end of the sixth month, a two weekwithdrawal period from leuprolide acetate ensued. During this period a10 mg oral dose of progesterone was given to pre-menopausal patients, toassess recurrence of symptoms and to induce menses. Post-menopausalwomen were not treated with progesterone during the 2 week withdrawalperiod. This procedure was then continued for an additional six months,with drug withdrawal and progesterone given every three months to inducea menstrual cycle. Serum estrodiol, progesterone, FSH, and LH werequantitated by radioimmunoassay prior to the initiation of leuprolidetreatment, and at three months post treatment initiation.

Results: Table 3 shows the clinical data on the five women studied. Themean age was 33.0+/-2.43 years, ranging from 28 to 41 years. The meanduration of symptoms was 8.0+/-2.02 years prior to the initiation ofleuprolide therapy.

                  TABLE 3                                                         ______________________________________                                        Clinical Information                                                                         Symptom                                                        Patient                                                                              Age*    Duration Diag- Prior   Prior                                   Number (Years) (Years)  nosis Surgery Therapy                                 ______________________________________                                        1      28*     6.5      GMD   None    Ephedrine                                                                     Lidamidine                                                                    Domperidone                                                                   Tylox                                   2      41*     5.0      GMD   Tubal   Lidamidine                                                            Ligation                                                                              Domperidone                                                                   Percodan                                3      31      16.0     IIHVN TAHBS/O°                                                                       Demerol                                                               95%     Tylox                                                                 Cholestomy                                      4      29      7.0      IIHVN Lapro-  Demerol                                                               scopy                                           5      36*     6.0      Roux- Vagotomy                                                                              Demerol                                                         en-Y  Roux-en-Y                                       ______________________________________                                         °TAHBS/O: Total abdominal hysterectomy with bilateral                  salpingooophorectomy                                                          *Pre-menopausal                                                          

The results of the leuprolide therapy on the patient's symptoms areshown in Table 4. The results of hormone assays prior to and aftertreatment with leuprolide for three months is shown in Table 5. Whenleuprolide treatment was stopped, and a progesterone challenge given toinduce menstruation, all subjects experienced recurrent symptoms withinthree to five days. Each subject had severe symptoms, some requiredhospitalization.

                  TABLE 4                                                         ______________________________________                                        Symptoms Before and After Leuprolide Acetate                                  Patient No.                                                                           Before           After                                                ______________________________________                                        1.      Pain: RUQ*,      Abolished                                                    epigastrium, BLQ°                                                      Nausea, daily    Decreased considerably                                       Intermittent vomiting                                                                          Abolished                                                    Worsened by ovulation                                                                          --                                                           Constipation     Daily formed stools                                  2.      Epigastric to RUQ pain                                                                         Abolished                                                    Nausea, daily    Abolished                                                    Worsened by ovulation                                                                          --                                                           Constipation, intermittent                                                                     Daily formed stools                                  3.      Epigastric to RUQ pain                                                                         Decreased considerably                                       Bilateral lower  Abolished                                                    quadrant pain                                                                 Nausea, daily    Abolished                                                    Obstipation      Daily formed stools                                          Pain on urination                                                                              Abolished                                            4.      Deep boring pain in lower                                                                      Abolished                                                    abdomen and rectum                                                            Constipation and urinary                                                                       Daily formed stools,                                         difficulty after normal urination                                             ovulation        (4-6 ×/day)                                    5.      Epigastric to RUQ pain                                                                         Abolished                                                    Worsened by eating                                                                             Abolished                                                    Nausea, daily    Abolished                                                    Intermittent vomiting                                                                          Abolished                                                    Diarrhea         Daily formed stools                                  ______________________________________                                         *RUQ: right upper quadrant                                                    °BLQ: bilateral lower quadrant                                    

                  TABLE 5                                                         ______________________________________                                        Gonadotropin Levels Before Leuprolide Therapy                                 and After 3 Months                                                            Patient No.                                                                           Gonadotropin                                                                             Baseline     After 3 Months                                ______________________________________                                        1.      Estradiol  44.0    pg/ml  13.0  pg/ml                                         Progesterone                                                                             3.0     n/ml   <0.25 n/ml*                                         LH         19.0    mIU/ml 6.0   mIU/ml°                                FSH        12.1    mIU/ml 9.0   mIU/ml                                2.      Estradiol  44.0    pg/ml  39.0  pg/ml                                         Progesterone                                                                             1.0     n/ml   <0.25 n/ml*                                         LH         16.0    mIU/ml 7.0   mIU/ml°                                FSH        13.0    mIU/ml 11.0  mIU/ml                                3.**    Estradiol  28.0    pg/ml  3.4   pg/ml                                         Progesterone                                                                             <0.25   n/ml   <0.25 n/ml                                          LH         18.4    mIU/ml 11.2  mIU/ml°                                FSH        32.0    mIU/ml 11.2  mIU/ml                                4.      Estradiol  20.0    pg/ml  5.5   pg/ml                                         Progesterone                                                                             3.0     n/ml   <0.25 n/ml*                                         LH         18.3    mIU/ml 5.0   mIU/ml°                                FSH        13.1    mIU/ml 7.9   mIU/ml                                ______________________________________                                         *P < 0.006                                                                    °P < 0.0004 (all values expressed as the mean + SEM of all four        subjects), compared with the baseline.                                        **Total abdominal hysterectomy and bilateral salpingooophorectomy        

Patients with GMD became symptom-free after treatment with leuprolide.Patient 3 (with IIHVN) responded dramatically despite having had a totalabdominal hysterectomy and bilateral salpingo-oophorectomy. Afterleuprolide therapy, nausea and vomiting subsided, and she developednormal bowel and bladder function. She does continue to experience mildand intermittent abdominal pain; however, the quality of her life hasbeen restored, and she has returned to work. Patient number 4 with IIHVNis now symptom-free. Patient number 5, with Roux-en-Y also respondeddramatically to leuprolide, therapy, is symptom-free and gained 35pounds, increasing from 96 to 131 pounds.

Treatment with leuprolide resulted in a significant decrease in thelevels of serum progesterone and LH. Estradiol and FSH levels alsodecreased. Bone desitometry findings were normal in all women at the endof the six months of treatment.

These results indicate that treatment with leuprolide acetate, a potentGnRH analog, successfully reduces or abolishes the debilitating symptomsof patients with Motility Disorders.

EXAMPLE 2 Treatment of Additional Patients Having Functional BowelDisorders

The procedure of example 1 was followed with additional patients. Thesepatients exhibited a range of functional bowel disorders as shown inTable 6. The majority of patients exhibited full recovery from symptomsof their disease in response to leuprolide treatment (Responded). Fourpatients of the twenty-six treated to date failed to respond to thetreatment (Failure). One of those who failed to respond was withdrawnfrom treatment due to side effects of bone pain (Side effects), and oneexpired as a result of bacterial endocarditis (Failure--expired). Onepatient listed as a failure elected to withdraw from the program after 4weeks of treatment. One patient after recovering from the symptoms ofher autonomic neuropathy expired from a massive myocardial infarction(Responded--expired).

                  TABLE 6                                                         ______________________________________                                        Diagnosis          Patient No.                                                                              Response                                        ______________________________________                                        Idiopathic Intestinal Hollow                                                                     13*        Responded                                       Visceral Myopathy/Neuropathy                                                                     18         Responded                                                          26*        Just begun                                                                    treatment                                       Gastrointestinal Motor                                                                           17         Responded                                       Dysfunction        19*        Responded                                                          20         Responded                                                          21*        Responded                                                          22*        Responded                                                          24*        Just begun                                                                    treatment                                       Pelvic Floor Dysfunction                                                                         7          Responded                                                          14         Failure                                         Chronic Intestinal Pseudo                                                                         8*        Responded                                       Obstruction        11*        Failure -                                                                     side effects                                                       15*        Responded                                       Roux-en-Y-Syndrome  9*        Responded                                                          10*        Failure -                                                                     withdrew                                                           12*        Failure -                                                                     expired                                                            16         Responded                                                          23         Responded                                                          25         Just begun                                                                    treatment                                       ______________________________________                                         *Pre-menopausal                                                          

The symptoms of Idiopathic Intestinal Hollow visceralMyopathy/Neuropathy include recurrent postprandial (worsened by eating)abdominal pain, distension of the stomach and small intestine, andintermittent vomiting. This disease also affects other hollow viscera,such as the alimentary tract, the ureters, the bladder, and the urethra.Fibrosis of the lens of the eye and the presence of hepatic portalfibrosis may also be associated. Frequently, lower quadrant pain isassociated, and may involve fallopian tube dysfunction.

The symptoms of Gastroduodenal Motor Dysfunction are unexplained chronicnausea, abdominal pain (usually right upper quadrant or epigastric andworsened by eating, stress, and post-ovulation) and intermittentepisodic vomiting.

Patients having Chronic Intestinal Pseudoobstruction complain offrequent and intermittent episodes of abdominal distention, nausea, andmay have episodic vomiting. X-rays of the abdomen may disclose air/fluidlevels suggestive of mechanical obstruction. Chronic IntestinalPseudoobstruction may include dilation of the small bowel, the dilationof the colon, and also severe gastric atony. Normal neural responses toswallowing and intestinal distention may be impaired.

The symptoms of the patients having pelvic floor dysfunction includedeep boring pain in the rectum and lower abdomen with altered bowel andurinary habits. This disorder is characterized by dysfunction of themuscles of the pelvic diaphragm.

The symptoms of the patients having Post Vagotomy Roux-en-Y Syndrome (asdefined in Mathias, Gastroenterology 88:101-107, 1985) include chronicnausea, vomiting, and postprandial abdominal pain.

These patients were treated with Leuprolide acetate following theprotocol established in Example 1.

Patient Number 13 is a 36 year old white woman first seen in 1976 forrecurrent abdominal pain. Between 1976 and 1978 she underwent anexploratory laporatomy, cholecystectomy (no stones), and asphincteroplasty of the sphincter of Oddi, however her symptomsworsened. In 1981, she underwent several MMC recordings of her smallintestine which revealed a several motor disorder consistent withchronic intestinal pseudoobstruction. She had been a participant inseveral experimental protocols with minimal success. Her symptomsprogressed to include difficulty in urination. Leuprolide acetatetherapy according to the protocol of example 1 was initiated in May,1988. Her symptoms improved dramatically, she no longer requiresparental alimentation for weight control, and urination has improved.

Patient Number 18 is a 40 year old white woman who had long standingproblems with nausea, abdominal pain, obstipation, and infrequenturination. When referred for evaluation, her disease was debilatatingand she was unable to work. Leuprolide acetate therapy according to theprotocol of example 1 was begun in November, 1988. Currently, all of hersymptoms have improved except for her obstipation.

Patient Number 17 is a 38 year old white woman referred for evaluationof nausea and chronic abdominal pain. She also suffers from longstanding chronic obstructive lung disease requiring multiple therapiesfor her breathing. An upper gastrointestinal X-ray series, upperendoscopy and ultra sound of the abdomen were normal. Leuprolide acetatetherapy according to the protocol of example 1 was begun in July, 1988.Her symptoms of nausea and chronic abdominal pain have abated. Inaddition, a smaller dose of Theoplylline is now required for her lungdisease, with dramatic improvement in pulmonary function tests seen.

Patient Number 19 is a 43 year old white woman referred for nausea andright upper quadrant pain. Upper gastrointestinal endoscopy, uppergastrointestinal X-ray series, and computerized axial tomography of theabdomen all displayed normal results. Endoscopic retrogradecholangiopancreatography disclosed a possible defect of the cystic ductof the gallbladder. Cholecystectomy was performed; however, thegallbladder bed was normal and no stones were found. Postoperatively,the patient's symptoms persisted. Leuprolide acetate therapy accordingto the protocol of example 1 was begun in August, 1988. After 6 weeks ofleuprolide acetate therapy, all symptoms had disappeared. After sixmonths of treatment, the patient was symptom free. The drug wasdiscontinued in March 1989 with no recurrent disease.

Patient Number 20 is a 65 year old white women referred for nausea,abdominal pain and constipation of many years duration. After extensiveevaluation by many previous physicians this patient was told her problemwas "in her head and she would just have to live with it". Leuprolideacetate treatment according to the protocol of example 1 was begun inOctober, 1988. The patient is now symptom-free.

Patient Number 22 is a 23 year old white woman referred for a 5 monthhistory of nausea, vomiting, abdominal pain, and the inability toswallow even her own saliva. She had been extensively evaluated, howeverno known diagnosis was found. In November, 1988 evaluations showed apositive Ebstein Barr titer of 1:1280 indicating ongoing chronicmononucleosis and associated gastroduodenal motor dysfunction.Leuprolide acetate therapy according to the protocol of example 1 wasbegun in December, 1988. A dramatic response was seen after three weeksof therapy. This patient is now able to swallow and eat.

Patient Number 7 is a 67 year old white woman seen in April, 1988complaining of severe deep boring rectal pain. She had previously beenevaluated by many physicians and was treated with antidepressantswithout relief. Conventional testing including upper gastrointestinalX-ray series, barium enema, colonoscopy, and Computerized AxialTomography of the abdomen all gave normal results. Leuprolide acetatetherapy according to the protocol of example 1 was begun in June, 1988.Within 8 weeks of therapy, this patient was symptom free.

Patient Number 8 is a 36 year old white woman first seen at the VAHospital in Gainesville, Fla., 1977. She had been in the army and wasgiven a medical discharge for chronic abdominal pain. Extensiveevaluation including laparotomy and cholesystectomy indicated no causeof disease. In 1981, MMC recording of her stomach and small intestinerevealed severe motor disease consistent with intestinalpseudoobstruction. Since that time she has participated in severalexperimental protocols without relief. Since 1985, this patient wasadmitted to the hospital at least one week per month for nasogastricsuction, hydration, decompressive colonscopy, and medical therapy.Treatment with leuprolide acetate according to the protocol of Example 1was begun in September, 1988. Since beginning leuprolide acetatetreatment, this patient does not chronically experience severe symptoms,and has had no hospital admissions since this drug therapy was begun.

Patient Number 15 is a 38 year old white woman who experienced abdominaldistention, fever, and was unable to maintain oral intake. She wasextensively evaluated at several institutions with no diagnosis reached.When evaluated in 1988, she required parental hyperalimentation forweight control. She had undergone exploratory laparotomy which revealedonly acute/chronic inflammation. Leuprolide acetate therapy according tothe protocol of example 1 was begun in March 1988. Her symptoms havesteadily improved, and she now requires no parental supplementation. Shehas returned to work.

Patient Number 16 is a 60 year old white woman with long standingnausea, vomiting, and abdominal pain following a gastro-jejunostromyRoux-en-Y anastamosis for alkaline reflux gastritis secondary to atruncal vagotomy and Bilroth II for intractable idiopathic peptic ulcerdisease. Her weight was 96 pounds. Leuprolide acetate therapy accordingto the protocol of example 1 was begun in August, 1988. Her symptomshave been relieved, and she is now able to eat and maintain her idealweight of 115-118 pounds.

Patient Number 23 is a 39 year old white woman who was evaluated in 1984for chronic nausea, vomiting, and abdominal pain following agastro-jejunostomy Roux-en-Y anastamosis for alkaline reflux gastritissecondary to a truncal vagotomy and Bilroth II for intractableidiopathic peptic ulcer disease. The use of opiates to control her paincaused the loss of her job as a registered nurse. Leuprolide acetatetherapy according to the protocol of example 1 was begun in November,1988. She is now symptom free, and does not require opiates for pain.

EXAMPLE 3 Treatment of Patients Having Previous Ovariectomy

Two patients discussed in Example 1 were women who had undergone surgeryfor removal of their ovaries. The first patient, Number 3, had undergonethis surgery approximately 2 years prior to beginning Leuprolide acetatetreatment. The second patient, Number 4, underwent ovariectomy 18 monthsafter beginning treatment with Leuprolide Acetate.

In both cases, the effective dose of leuprolide acetate was higher thanthe effective dose required by patients who had not had ovaries removed.

Patient Number 3 was given a daily dose of Leuprolide acetate initiallyat 0.5 mg. This was increased to 1.0 mg in order to overcome hersymptoms.

Patient Number 4 was symptom free with the daily dose of 0.5 mg ofleuprolide acetate prior to the removal of her ovaries. Post-ovariectomyhowever, this dose was not sufficient. An effective daily dose of 1.0 mgwas found to relieve her symptoms.

EXAMPLE 4 Leuprolide Acetate Effects on Migrating Motor Complexes inRats

Eleven female Wistar rats weighing between 175 and 250 g were eachimplanted with four bipolar Ag/AgCl electrodes (the preparation of whichis described in: Mathias, Am. J. Physiology, 249:G416-G421, 1981). Theelectrodes were sewn 5 cm from the Ligament of Trietz and 5 cm apart,onto the jejunal serosa. The number of migrating myoelectric complexeswas recorded using a R-612 Dynograph (Sensor-Medics, Anaheim, CA). Ratswere fasted for 36 hours prior to recording and feeding (no food,liberal water), and were housed in special cages to remove feces. After36 hours of fasting, Migrating Motor Complexes (MMC) were recorded at asensitivity of 0.2 mV/cm, 2.5 mm/sec paper speed, and a Time Constant of1 for a duration of 2 to 4 hours. Immediately following the fastedrecording session, the rats were fed 2 biscuits of Purina rat chow withsimultaneous recording during feeding and continued for 4 hours.

This procedure was followed for 2 to 4 recording sessions prior to thetreatment with leuprolide acetate (Controls).

Leuprolide acetate was then administered daily, in the morning,subcutaneously in the hind limb at a dose ranging from 2 to 40 ug/100 gbody weight. After a period of at least 24 hours post treatment withleuprolide, the fasting/fed recording sessions were begun as describedfor the controls to obtain recordings through 2 to 4 sessions. Theresults are shown in Table 8.

                  TABLE 8                                                         ______________________________________                                        Migrating Motor Complexes (MMC/hour)                                          CONTROLS           TREATMENT                                                  Dose  Fasted    Fed        L-Fasted L-Fed                                     ______________________________________                                        2   ug    4.69 ± 0.24                                                                          2.60 ± 0.27.sup.                                                                    4.60 ± 0.12                                                                         4.83 ± 0.65*                         20  ug    4.43 ± 0.25                                                                          1.40 ± 0.48ƒ                                                               5.41 ± 0.17                                                                         4.11 ± 0.22*                         40  ug    4.75 ± 0.48                                                                          2.33 ± 0.33.sup.                                                                    4.48 ± 0.12                                                                         3.45 ± 0.25*                         ______________________________________                                         *Represents inhibition of the fedstate; all values expressed as the mean      ± SEM                                                                      .sup. P < 0.001, Fed versus LupronFed                                         ƒ P < 0.0001, Fed versus LupronFed                                   .sup. P < 0.017, Fed versus LupronFed                                         L-Fasted and LFed denotes Lupron treated animals                         

These results show the reduction in the MMC/hour in female rats in thefed state is eliminated in rats treated daily with as little as 2 μg/100g body weight of leuprolide acetate.

EXAMPLE 5 Leuprolide Acetate in Ovariectomized Female Rates

Female Wistar rats were ovariectomized and permitted to recover tendays. Bipolar Ag/AgCl electrodes were then implanted as described forexample 4. Control MMC readings in the fasted and fed states wererecorded prior to treatment with leuprolide acetate (Controls) asdescribed in Example 4.

Treatment with leuprolide acetate followed using doses in the range of 2to 250 ug/100 g body weight. Fasted and fed recordings were obtained asdescribed for Example 4. The results of these studies are shown in Table9.

                  TABLE 9                                                         ______________________________________                                        Migrating Motor Complexes in                                                  Ovariectomized Rats (MMC/hour)                                                OVX-CONTROLS        OVX-TREATMENT                                             Dose   Fasted    Fed        L-Fasted                                                                              L-Fed                                     ______________________________________                                        2    ug    3.86 + 0.14                                                                             0        4.40 + 0.16                                                                           0                                       20   ug    5.17 + 0.31                                                                             0        5.40 + 0.15                                                                           0                                       40   ug    4.50 + 0.22                                                                             0.88 + 0.58                                                                            5.23 + 0.41                                                                           0                                       100  ug    4.00 + 0.17                                                                             0.sup.   5.00 + 0.41                                                                           4.50 + 0.34*                            250  ug    4.50 + 0.22                                                                             0.88 + 0.58ƒ                                                                  4.50 + 0.29                                                                           5.00 + 0.58*                            ______________________________________                                         All values expressed as the mean + SEM;                                       *denotes inhibition of the fedstate                                           .sup. P < 0.0001 Fed versus LFed                                              ƒ P < 0.0001 Fed versus LFed                                         L-Fasted and LFed denotes Lupron treated animals                         

These results show that higher doses of leuprolide acetate (100 ug/100 gbody weight) are required to overcome the reduction of MMC/hour in fedfemale rats.

EXAMPLE 6 Treatment of End Stage Scleroderma

Scleroderma is defined as a chronic disease of unknown cause,characterized by diffuse fibrosis, degenerative changes, and vascularabnormalities in the skin, articular structures, and internal organs,especially the esophagus, intestinal tract, thyroid, lung, heart, andkidney.

Patient number 6 was in end-stage scleroderma. She had been bed-riddenfor approximately 8 months, unable to retain food after eating, and wasbeing maintained on total parental hyperalimentation (TPN) to keep upbody weight and fluid and electrolyte balance for 5 months.

This patient was treated with 0.5 mg Leuprolide acetate daily, bysubcutaneous injection according to the protocol of example 1. After 5weeks of therapy, she was able to move about actively, and did notrequire the TPN feeding. She was discharged from the hospital, waseating without difficulty, and had gained weight.

After 4 months of therapy, and recovery from the gastrointestinalproblems associated with her disease, this patient suffered a severemyocardial infarction and expired. Her death was attributed to theduration and complications associated with her disease and did notimplicate the use of the medication given.

I claim:
 1. The process for treating a subject exhibiting the symptomsof Motility Disorders, comprising:administering to the subject atherapeutically effective dosage of a compound comprising an analog ofGonadotropin Releasing Hormone.
 2. The process of claim 1, wherein saidMotility Disorder is selected from the group comprising Functional BowelDisease and Irritable Bowel Syndrome.
 3. The process of claim 1, whereinsaid Motility disorder is Functional Bowel Disease.
 4. The process ofclaim 3, wherein said Functional Bowel Disease is selected from thegroup comprising: Gastroduodenal Motor Dysfunction, IntestinalPseudo-Obstruction, Idiopathic Intestinal Hollow VisceralMyopathy/Neuropathy, Severe Intestinal Constipation, and Post-VagotomySyndromes.
 5. The process of claim 1, wherein said analog is a compoundof the formula:

    pGlu - His - Trp - Ser - Tyr - X - Leu - Arg - Pro - NHC2H5,

wherein X represents an amino acid of the D-configuration.
 6. Theprocess of claim 2, wherein said analog is a compound of the formula:

    pGlu - His - Trp - Ser - Tyr - X - Leu - Arg - Pro - NHC2H5,

wherein X represents an amino acid of the D-configuration.
 7. Theprocess of claim 3, wherein said analog is a compound of the formula:

    pGlu - His - Trp - Ser - Tyr - X - Leu - Arg - Pro - NHC2H5,

wherein X represents an amino acid of the D-configuration.
 8. Theprocess of claim 4, wherein said analog is a compound of the formula:

    pGlu - His - Trp - Ser - Tyr - X - Leu - Arg - Pro - NHC2H5,

wherein X represents an amino acid of the D-configuration.
 9. Theprocess of claim 1, wherein said analog is a compound of the formula:

    pGlu - His - Trp - Ser - Tyr - D-Leu - Leu - Arg - Pro - NHC2H5.


10. The process of claim 2, wherein said analog is a compound of theformula:

    pGlu - His - Trp - Ser - Tyr - D-Leu - Leu - Arg - Pro - NHC2H5.


11. The process of claim 4, wherein said analog is a compound of theformula:

    pGlu - His - Trp - Ser - Tyr - D-Leu - Leu - Arg - Pro - NHC2H5.


12. The process of claim 4, wherein said analog is a compound of theformula:

    pGlu - His - Trp - Ser - Tyr - D-Leu - Leu - Arg - Pro - NHC2H5.